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Fig. 2. Tracheostomy status of different Cotton-Myer, Lano, and McCaffrey stages at last follow-up. For Cotton-Myer staging, asterisk denotes statistical significance between grade I and II vs. grade III and IV (A). Diagnosis of tracheomalacia stratified by etiology. Asterisk denotes statistical significance between iatrogenic etiology and all other groups (B). Rate of tracheostomy in iatrogenic etiology patients with and without a diagnosis of tracheomalacia. Asterisk denotes statistical significance (C).

DISCUSSION Although most airway stenosis appears similar on anatomic imaging and clinical examination, we present data supporting the hypothesis that different mecha- nisms of injury are associated with differing rates of long-term tracheostomy dependence. The relationships between the anatomic stenosis characteristics (% steno- sis, location, and length) and endoscopic or open surgical “success” have been established through pioneering work in children 8,9 and adults. 7 In advanced centers, proce- dural intervention for LTS offers a high rate of long- term tracheostomy free survival. 4,10,11 However, success in these large published series remains critically depend- ent on patient selection. With our consecutive series of both inpatient and outpatient consultations, we believe that this study captured a more representative cross- section of symptomatic LTS patients than many prior adult surgical case series. In the “real world,” those patients deemed poor operative candidates (e.g., sicker patients) are often left with limited therapeutic options regardless of the structural morphology of their stenosis. Endotracheal intubation and tracheostomy can be lifesaving but should not be considered benign proce- dures. They harbor significant long-term risks to commu- nication, 12 swallowing, 13 and breathing, 14 particularly in the subset of patients with comorbid illness. 15 Ironically,

etiologic groups was seen in all three established LTS classification systems (Table IV). Tracheal Structural Instability. Patients with iatrogenic injuries had a significantly higher rate of tra- cheomalacia observed on bronchoscopic evaluation (37% vs. 8%; P < 0.001; Fig. 2B). Given the retrospective nature of this work, it is not possible to establish a caus- ative relationship between the initial injury and the loss of structural integrity associated with tracheomalacia. However, it is interesting that among the iatrogenic group, 45% of patients without malacia required trache- ostomy, whereas 97% of those with malacia necessitated long-term tracheostomy ( P < 0.001; Fig. 2C). Multivariate Analysis Multivariate regression analysis was performed to determine independent predictors of ultimate tracheos- tomy dependence. Each additional point on CCI was associated with a 67% increased odds of tracheostomy dependence (odds ratio [OR] 1.67; 95% CI 1.04–2.69; P 5 0.04). Moreover, there was a 3% increased odds of tracheostomy dependence for each additional percentage of airway compromise (OR 1.03, 95% CI 1.01–1.06; P 5 0.001). LTS patient characteristics (etiology, age, sex, race) were not significantly associated with odds of tra- cheostomy dependency.

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